Involuntary Treatment is Not Enough

By Erik Roskes

In a recent article, researchers from the University of South Florida correlated arrest rates with recent histories of involuntary commitment.  They found that people who underwent an involuntary psychiatric evaluation were 12 percent more likely to be arrested in the three months after that evaluation than people who had not been involuntarily evaluated.

The Crimes of the Mentally Ill: A Creative Response

By Erik Roskes

In a recent article in the New York Times, author Deborah Sontag details a tragic sequence of events in Massachusetts in which the primary players are a seriously mentally ill man and the minimally trained mental health worker whom he kills.

Solitary Confinement, Not So Bad After All?

Long-term solitary confinement in prison has long been a source of controversy as most literature and critics of the process say it exacerbates mental illness.

The Tucson Tragedy and Mental Health: Beware of Simplistic Responses

Too much of the initial response to the terrible tragedy in Tucson calls to mind the kind of reflexive response which health specialists refer to as a spinal reflex arc.  The best example is when you touch a hot stove – your arm recoils in a jerky, sudden manner, before you ever consciously feel the pain.  This is so because the brain is not involved in the response. The painful stimulus travels from your finger up the sensory nerve to the spinal cord, triggering a motor response back down the motor nerve that pulls the arm back.

No brain required for this response.  But we have seen it, unfortunately,  many times over the past few days.

The reason for this response style is the demand of the 24-hour news cycle for talking heads, even if the heads may not really know what they are talking about.  This cycle is driven by our human need for a definitive answer, even when a definitive answer is hard to find.  The best example I have ever seen of this irrational need is “forty two”, which, according to Douglas Adams, in his remarkably sage Hitchhiker’s series, is “the answer to the ultimate question of life, the universe and everything.”  The problem is – what’s the question?  And yet, the answer “forty two” sounds so certain that it satisfies us, if we don’t spend too much time thinking about it.

Unlike many esteemed (and not so esteemed) mental health professionals, I believe that it is irresponsible and unethical to render a diagnosis on an individual whom I have never seen nor evaluated professionally.  It is said that the alleged killer Jared Loughner has “schizophrenia,” and he may well suffer from that or some similar illness.

The little that I have seen of his writings and videos certainly seems bizarre and perhaps frankly delusional.  Some of my friends and coworkers have apparently concluded that his psychosis (if he has one) renders the politics behind his actions irrelevant.  To take this view to its logical conclusion, if only we had better/more accessible/cheaper mental health care, this tragedy would have been avoided.

Others have concluded that Loughner was a right-wing “wing-nut”, and they see his behavior stemming from any number of politically driven motives.  In this explanation, if only our political discourse was more civil and respectful, the tragedy could have been avoided.

Still others view the ease of access to weapons in Arizona as the “lowest common denominator” here. While I personally find this to be among the most reasonable arguments, it is, like all of the other “obvious solutions,”  incomplete.  Even if Arizona had more restrictive gun laws, we all know that guns are readily available through extra-legal channels, and that had Loughner been suitably motivated, he would have been able to obtain the weapons he needed.  However, proponents of this argument assert that with stricter gun laws, the tragedy could have been avoided.   As H.L. Mencken once observed, “There is always an easy solution to every human problem—neat, plausible, and wrong.”

I have heard and read about individuals who claim that “if only” any one of these solutions were in place, this tragedy never would have occurred.  I believe that such “easy solutions” do more to make us feel better than they do to resolving the complexities of human behavior.  In my own practice, I have worked with a number of individuals charged with committing crimes on school grounds.

For example, Florence was charged with trespassing on school grounds at the community college where she was taking classes. A 47-year-old returning student, Florence was observed by her classmates spraying an unknown substance on her desk and wiping it off.  She also sprayed the floor around her seat.  When approached by the instructor and asked to stop, Florence pulled out a small knife from her purse.  The campus police were called, and they removed her from the campus.  She was subsequently suspended for a semester, after an administrative review.  When she later returned, she was charged with trespassing.

In court, Florence appeared odd and disorganized, and appeared to be unable to understand the court proceeding. She was found incompetent to stand trial and committed for treatment.  She responded to medication, her thoughts became more organized, and she agreed to follow her outpatient treatment.

Is Florence the next Jared Loughner?  She is likely to return to school, as she wants to obtain her degree.  Her family is supportive of her continuing treatment, recognizing that she suffers from a mental illness.  But will she follow her doctor’s recommendations?  How can any of us really know?

These sorts of incidents happen all the time, all over the country.   For every Jared Loughner, there are literally thousands of others dealing with mental illness, with varying levels of compliance to their treatment plans, who never engage in such extreme violence.

What about politics?  From the little I have seen, it appears to me that Jared Loughner built a set of beliefs around his extreme political views.  I have had people tell me that if he has schizophrenia, his politics are irrelevant and meaningless.  Frankly, I find this to be an extreme example of “all or nothing” thinking.

Any mental health professional has been involved with people who build delusions around aspects of reality in their world.  We have all heard of the paranoid delusion that “the CIA is after me” as a motivator for engaging in defensive actions, such as covering windows with heavy material.  Well, the CIA really is after some people – this is reality.  Whether the CIA is actually after my patient is rather more doubtful, but it is certainly possible, isn’t it?

In this case, it appears to me from where I sit that the most likely truth is that Jared Loughner built a complex delusional system around his political views.  Does this mean that Sarah Palin or anyone else is personally to blame?  Of course not.  Does it mean that the nature of our political discourse plays a role in the extreme views that Loughner developed?  Perhaps.  (That said, anyone interested in extreme political discourse should review some of the political literature of the eighteenth century, both before and after the Revolution—some of which led to a fatal duel between Hamilton and Burr.)

Now, as to guns:  it is clear to me that had Loughner not had access to the weaponry he obtained, he would have had a more difficult time perpetrating this tragedy, as he is alleged to have done.  But it is simplistic to lay all of this on easy access to guns, without considering the role of the gun owner.  The Crime Report has already discussed gun ownership and mental illness, and this will continue to be problematic in a country that so values its liberties.  Personally, I believe guns should not be easy to obtain, and it strikes me as problematic that guns are so easy to obtain while mental health care is so hard to obtain, and getting harder.

I am aware that in the past few years, services have been cut around the country—and in Arizona—in the face of our budgetary struggles.  I see this every day in my own work, and I have already written about this.

Do I believe mental health care should be more accessible?  Yes. Do I believe that it should be easier to force treatment on the unwilling?  Now, that’s a more complex question that requires the balancing of personal liberty with public safety, isn’t it?  For those who would like to see this as a psychotically driven act divorced from politics, an argument I have seen primarily from those on the right, how do you answer this question while still arguing for less government intrusion into our lives?  If one wants to view this simplistically as all schizophrenia, it logically follows that “we the people” must provide adequate funding for more and better services, something that runs counter to the “cut taxes and make government smaller” platform.  Further, those who want to see this as psychotically driven and not as politically motivated should be satisfied with a finding of “not guilty by reason of insanity” (a very unlikely result),  rather than of guilt.

This was a terrible tragedy. On that we all agree.  While I have seen many reflexive responses, absent among them is a recognition of the following two truths:

First, predicting violence or aggression is very difficult.  Psychiatrists and other mental health professionals in many jurisdictions are asked to do just this.  While we may have some ability to forecast in the near term, our predictive power over time diminishes rapidly.  A proper assessment is complex and time consuming.  The best way to understand what we do is to think about our work as more akin to a weather forecast than it is to a true prediction.  We are more accurate when considering the likelihood of an event occurring in the near future.

Second, violent events are prevented every single day, many times a day, by our public safety and, yes, our mental health professionals around the country.  Each day, in our streets, in our schools and in our emergency rooms, people in crisis are assessed, helped to find safer places, and escorted to treatment settings, and tragedies are avoided.  The problem is: how do we prove a negative?

So, for those still reading, here is my conclusion:  There is no one single answer to this problem, which is complex and, like most, multi-determined.  The genesis of Loughner’s alleged actions will be found in politics, in mental illness, and in easy access to guns.  All of these issues should be addressed in a logical, thoughtful manner—not by reflex, not without thinking.

What makes us human is our ability to consider passionate issues in a dispassionate manner.  We need to respect each other, while still asserting our views and ideas.  But at the end of the day, it is our higher level cognition and ability to think things through, and not our reflexive ability to avoid pain, that is likely to lead us to the best possible answer.

Erik Roskes is a forensic psychiatrist and currently the Director of Forensic Services at the Springfield Hospital Center in Maryland. The opinions expressed are those of the author only, and do not represent those of any of Dr. Roskes’ employers or consultees, including the Maryland Department of Health and Mental Hygiene.

The Tucson Tragedy and Mental Health: Beware of Simplistic Responses

By Erik Roskes

Loughner May Cite “Diminished Capacity” To Fight Execution

It’s not clear yet whether attorneys for Jared Loughner’s lawyers will attempt the insanity defense in the shooting of Rep. Gabrielle Giffords (D-AZ), but John Hinckley’s successful insanity claim after shooting President Ronald Reagan led Congress to raise the bar, making the task harder, says the Associated Press. It is expected that the Justice Department will seek a death penalty.

Before the attempted assassination of Reagan, Harvard Law School Prof. Alan Dershowitz told AP, ”this would be a clear case of insanity, because the pre-meditation would not be seen as undercutting insanity, it would be part of demonstrating insanity.” Under the post-Hinckley rules, “that’s a very uphill battle.” Public outrage over the jury’s verdict in Hinckley’s trial — not guilty by reason of insanity — prompted Congress to make it much more difficult to establish that claim in federal criminal trials. Arizona has modified the insanity defense so that a defendant there no longer can be found not guilty by reason of insanity. Instead, the jury can deliver a verdict of guilty but insane. “So the person is held at a state mental hospital, and if sanity somehow comes back, he’s transferred to prison, not just let go,” said Prime County prosecutor Barbara LaWall said. More likely, Loughner’s defense will argue that he was mentally impaired. That concedes that he bears some responsibility for what he has done but lacks the guilt necessary to face the death penalty. That state of mind sometimes is called “diminished capacity.”

Link: http://www.law.com/jsp/article.jsp?id=1202477639410&Insanity_Defense_Could_Be_Difficult_for_Ariz_Shooting_Suspect

Loughner May Cite "Diminished Capacity" To Fight Execution

It's not clear yet whether attorneys for Jared Loughner's lawyers will attempt the insanity defense in the shooting of Rep. Gabrielle Giffords (D-AZ), but John Hinckley's successful insanity claim after shooting President Ronald Reagan led Congress to raise the bar, making the task harder, says the Associated Press. It is expected that the Justice Department will seek a death penalty.

Before the attempted assassination of Reagan, Harvard Law School Prof. Alan Dershowitz told AP, "this would be a clear case of insanity, because the pre-meditation would not be seen as undercutting insanity, it would be part of demonstrating insanity." Under the post-Hinckley rules, "that's a very uphill battle." Public outrage over the jury's verdict in Hinckley's trial -- not guilty by reason of insanity -- prompted Congress to make it much more difficult to establish that claim in federal criminal trials. Arizona has modified the insanity defense so that a defendant there no longer can be found not guilty by reason of insanity. Instead, the jury can deliver a verdict of guilty but insane. "So the person is held at a state mental hospital, and if sanity somehow comes back, he's transferred to prison, not just let go," said Prime County prosecutor Barbara LaWall said. More likely, Loughner's defense will argue that he was mentally impaired. That concedes that he bears some responsibility for what he has done but lacks the guilt necessary to face the death penalty. That state of mind sometimes is called "diminished capacity."

AZ Courts Can Order Psychiatric Evaluations Absent Crime

Unlike many states – where little can be done to force an unstable person into treatment until he or she becomes violent and poses a danger to themself or others - any person in Arizona can ask a court for a psychiatric evaluation solely because a person appears to be mentally ill and doesn’t know it. That doesn’t appear to have happened in the case of Jared Loughner, accused of shooting Rep. Gabrielle Giffords (AZ), says the Washington Post.

“When people appear mentally ill or show some instability, how do you get them to [mental health] resources if the system doesn’t know those people are out there?” said Neal Cash of Community Partnership of Southern Arizona, which provides mental health services.  “Our crisis line is manned 24/7. Anyone concerned about his behavior could have called at any time.” The Tucson community college that expelled Loughner for disruptive behavior “dropped the ball,” said E. Fuller Torrey, a psychiatrist who founded the Virginia-based Treatment Advocacy Center. “At least they got him off campus, so they can say, ‘We’ve discharged our responsibility, we’re protecting our students.’ I suppose they could argue, ‘We don’t have responsibility for the larger community.’ “

Link: http://www.washingtonpost.com/wp-dyn/content/article/2011/01/10/AR2011011007049.html?hpid=topnews

AZ Courts Can Order Psychiatric Evaluations Absent Crime

Unlike many states - where little can be done to force an unstable person into treatment until he or she becomes violent and poses a danger to themself or others - any person in Arizona can ask a court for a psychiatric evaluation solely because a person appears to be mentally ill and doesn't know it. That doesn't appear to have happened in the case of Jared Loughner, accused of shooting Rep. Gabrielle Giffords (AZ), says the Washington Post.

"When people appear mentally ill or show some instability, how do you get them to [mental health] resources if the system doesn't know those people are out there?" said Neal Cash of Community Partnership of Southern Arizona, which provides mental health services.  "Our crisis line is manned 24/7. Anyone concerned about his behavior could have called at any time." The Tucson community college that expelled Loughner for disruptive behavior "dropped the ball," said E. Fuller Torrey, a psychiatrist who founded the Virginia-based Treatment Advocacy Center. "At least they got him off campus, so they can say, 'We've discharged our responsibility, we're protecting our students.' I suppose they could argue, 'We don't have responsibility for the larger community.' "

When the Defendant Has TBI

By Erik Roskes

Forensic psychiatrist and The Crime Report blogger Erik Roskes relates the odyssey of a young man who became involved in the criminal justice system after sustaining a traumatic brain injury.

Zack is a 38-year-old man who had no mental health history into his early adulthood.  He was an occasional user of marijuana and a weekend drinker, and he experimented with cocaine and amphetamines, but never used these latter drugs regularly.  At age 26, he was in a low-speed motorcycle accident, resulting in a brief (less than an hour) period of unconsciousness, and no obvious problems in the immediate aftermath of the accident other than a broken arm.

During the next several years, Zack began to engage in more risky behaviors, including heavier drug use and speeding on his motorcycle.  When he was 29, working on a construction site, he fell about three stories, sustaining a much more severe traumatic brain injury (TBI).  On this occasion, Zack was in a coma for over two weeks, and required many months of rehabilitation and therapy before he could walk independently.

Over the years since the second brain injury, Zack was noted to be very impulsive, frequently engaging in fights with family, strangers, and the police.  He was found to be eligible for state-funded services for people with adult-onset TBIs.  However, after a year in a placement in which he was doing well, Zack decided he no longer wanted the services, preferring to live independently, against the advice of his treatment providers.  He resumed his use of alcohol and drugs when not in a restricted environment.  Eventually, he was charged with disorderly conduct, failing to obey an order, and resisting arrest.

Upon review, the court deferred trying the case, recommending that Zack return to a treatment or rehabilitation program. Instead, Zack stayed for a few weeks with his brother, but his behavior became too frightening to his brother and his brother’s family. He became homeless, and missed a review hearing. When he did finally appear back in court, he was convicted of the charges.  However, the court and his public defender were concerned that he would not do well in jail or prison, given his difficulties stemming from his TBI, and sentencing was deferred, again with a recommendation that he seek care.

During the next year, he again became homeless again. Finally, misbehaving in public again, the police decided not to arrest him but instead brought him to a local emergency room. He was found to be intoxicated and psychotic, and over several days in the ER, he stabilized and returned to his current baseline, which included impulsivity and poor frustration tolerance, but a rather friendly demeanor overall.

The hospital’s psychiatry unit declined to admit him, as his symptoms related to a brain injury and not a psychiatric illness.  The neurology and medical units refused him, as his presentation after stabilization did not represent an acute illness but rather his long-term TBI-related problems. He remained in the ER for over two weeks, until the court (remember, he still had an open case) ordered him admitted to the state psychiatric unit for a competency evaluation.

On admission, it was evident that Zack was not receiving the sorts of treatment, rehabilitation, or management that he required.  The state hospital staff learned that the only way to access TBI services was to arrange for his admission to a TBI unit at a publicly funded rehabilitation hospital. Time was of the essence—his Medicaid would be terminated if he remained in the state psychiatric hospital for more than 30 days under a court-commitment. If that happened, the only way he could again become Medicaid eligible would be to have his court commitment resolved.  Of course, as you recall, the way the court wanted to resolve the case was to get him into a treatment program. A real Catch 22, right?

As it happened, we at the state hospital were able to collaborate with the state’s TBI program to orchestrate a rapid transfer from the psychiatric hospital to the TBI unit at the rehabilitation facility. This took many hours of work, but with the collaborative approach on the part of staff at both hospitals, at the state’s TBI program, and the support of the state’s psychiatric and medical administrators, as well as the Court and counsel, Zack was transferred to the TBI unit last week.

The next steps include ensuring that he has long-term care Medicaid and then identifying the proper program for his ongoing treatment and rehabilitation.

Had it not been for a judge interested in doing the right thing, rather than the easy thing, Zack would likely have ended up in jail or prison, where he would likely not do well given his impulsivity and poor frustration tolerance.  Many readers will be aware of the recent attention to TBI in professional sports.  We can expect many many more, given the numbers of war veterans returning with TBI’s.

How many Zack’s are there in jails and prisons?  How can society get them needed care, treatment, and rehabilitation in order to avoid these terrible outcomes?

Erik Roskes is a forensic psychiatrist and currently the Director of Forensic Services at the Springfield Hospital Center in Maryland. The opinions expressed are those of the author only, and do not represent those of any of Dr. Roskes’ employers or consultees, including the Maryland Department of Health and Mental Hygiene.

Photo by jugbo via Flickr.

Standing up for "Disposable" People

By Erik Roskes

Well, after six weeks, our Iraqi visitors have returned home. During their visit, they told us that things were becoming more difficult at home, and one of them was considering relocating to the US, if possible, even knowing that he likely would never be able to practice psychiatry here.

During their visit, we became close colleagues and friends.  It was amazing to me how easy it was to get close to them, how much more alike we all are than one would think.  As the psychiatrist and psychoanalyst Harry Stack Sullivan said over a half-century ago, “We are all more human than otherwise.”

Think about the lesson this teaches us.  We who choose to work within the criminal justice system have chosen to work with those whom society has deemed “disposable” people.  I’m not saying that some—maybe many—incarcerated people have done quite horrible things.  The recent case in Connecticut reminds us that there are, in fact, evil people in the world.

But, many people with mental illness are unfortunates who suffer with serious impairments in their decision-making capacities, their insight, at times even their volitional control.  For many of these individuals, jail is the only place that doesn’t say no.  I have already described a woman arrested for “being mentally ill in public.”

Here’s another case: 20 year old Ryan is arrested after seriously assaulting his mother.  He is a talented student athlete, home from college for winter break.  After describing his actions as “I had to do it – she was possessed,” he is referred for a psychiatric evaluation and found to be suffering with a psychotic illness rendering him severely delusional.  He denied drug use, and his urine and blood are clean.  He is admitted to a hospital, treated with medications and therapy, and within 2 weeks has become asymptomatic.  Profoundly remorseful over what he has done, he becomes severely depressed.

What should happen to Ryan, who is so similar to you, reading this blog, and to me, writing it?  Should he be charged with assault?  Should he be diverted for treatment?  Both?

In our country, we struggle mightily with issues of liberty and personal autonomy, and conversely with holding people accountable for their choices.  But accountability assumes the freedom to make choices – and Ryan’s case, can we truly conclude that he made a free choice while struggling with a new-onset psychosis?

Back to my opening: We are all more human than otherwise.  Cases like Ryan, so similar to me when I was a student – except, of course, for the psychosis and the athletic skills – make me ever grateful that I have not developed a serious mental illness.  Meeting my new friends from Iraq, where psychiatrists are held hostage for ransom, or even occasionally assassinated, make me ever grateful that I was born here in the US.   But at the end of the day, we are all pretty much the same, but for the random nature of where we were born, what genes we are born with, and what our early life experiences are.

Finally, if you are losing faith in the positive impact you can have on those you serve, read Phil Taylor’s latest column in Sports Illustrated.

Erik Roskes is a forensic psychiatrist and currently the Director of Forensic Services at the Springfield Hospital Center in Maryland. The opinions expressed are those of the author only, and do not represent those of any of Dr. Roskes’ employers or consultees, including the Maryland Department of Health and Mental Hygiene. He can be found at http://mysite.verizon.net/eroskes/

A Tale of Two Countries: Building A Mental Health System in Iraq, Part 2

“The best of times, the worst of times…”

A rich, well-resourced country of over 300 million people – a beacon of hope and democracy around the world.  Alas, also the world leader in incarcerating people.  What have we done wrong?

A country decimated by years of neglect by its leader – worse, by the systematic rape of its resources by that leader.  Thirty years during which, reportedly, 97% of the country’s expenditures went to the military.

As promised in my last blog posting, this blog will focus on a visit by four Iraqi mental health professionals brought to the US to study forensic mental health services.  As of this writing, they have been here for four weeks, with two more ahead of us.  What have we shown them?

Upon arrival, they had the opportunity to spend a few days touring in DC while they accommodated to our time zone.  Then, SAMHSA arranged for a “convening conference,” during which the forensic team and the five other Iraqi teams (two focusing on trauma, two on child mental health, and one on substance abuse) met with folks from the various host sites, shared their hopes for the visit, had a discussion on human rights, participated in an Anti-Stigma Workshop, and then dispersed to their host sites.

In the first week, our new Iraqi friends were introduced to the forensic mental health system in Maryland.  We held a series of meetings over two days, during which they met various decision-makers and thought-leaders from the mental health and criminal justice systems in Maryland, had a tour of the Clifton T. Perkins Hospital Center (the maximum security hospital in Maryland), followed by a three day forensic training provided by the state Office of Forensic Services for new forensic evaluators.

During the second week, we spent two more days at Perkins, as well as a full day at the Patuxent Institution, a state correctional facility with a long history of focusing on offenders using a variety of treatment and rehabilitative approaches.  In the third week, we branched out a bit, accommodating the interest of our visitors in community-based services.  We spent a day at Springfield Hospital Center, where I work, and two days visiting community programs – the Arundel Lodge program in Annapolis and the Forensic Assertive Community Treatment Team (FACTT) offered by People Encouraging People, Inc., in Baltimore.  In addition, we spent two days observing mental health courts in the district courts of Baltimore and Prince George’s County.

While I cannot speak directly to what they have learned, the questions they ask and the discussions we have had are eye opening.  As I wrote in my last posting, the 32 million people in Iraq are served by about 120 psychiatrists.  There are two psychiatric hospitals for the entire country.  Both are located in or near Baghdad.  Al-Rashad Hospital, where the visiting team works, is a 1200 bed long-term hospital, with about 250 beds set aside as a highly secure forensic unit.  The clinical staff there includes 10 psychiatrists, 125 nursing staff, 4 social workers, and 6 psychologists.  There are no designated rehabilitation staff, such as occupational or activity or expressive arts therapists, though many of the other clinicians provide an array of psychiatric and rehabilitative treatments, including some absolutely amazing expressive arts therapies.  For example, one of our visitors, a nurse, writes poetry and plays, which the patients perform.

Compare this to my hospital, which has about 270 patients, who are treated by 25 psychiatrists, 336 nurses, 26 social workers, 14 psychologists, and 68 rehabilitative staff.  If they were staffed commensurate to my hospital, they would have 111 psychiatrists, almost 1500 nursing staff, 113 social workers, 62 psychologists, and 300 rehabilitation staff.  We have over 3 times the number of staff, to serve a caseload that less than one-quarter of that at Al-Rashad.  And we think we struggle to do more with less.  Of course, when bad things happen, one of the first proposed causes is inadequate staffing – see this story regarding a recent tragedy at Clifton T. Perkins Hospital.  Even our staffing levels, as rich as they seem when compared to Iraq, are still pretty poor when focusing on public sector services for court-involved people with mental illnesses.

Also lacking in Iraq is any formal system of community-based services for people with mental illness.  When a patient is treated to the point where she can leave the hospital, she is given a month supply of medication and told to follow up at Al-Rashad or a hospital closer to her hometown.  Patients are discharged home with their families – there are no supportive or residential rehabilitation programs, no group homes, no assisted living facilities, no alternatives.  There are no day programs, no ACT programs, no collaborative mental health-criminal justice programs – there is no conditional release of any kind.  And yet, they manage to discharge people back into their communities, somehow or other.  It is truly humbling.

In my next posting, I will discuss the closure of the visit, including the work that we have been able to initiate with them regarding what aspects of our system they might rationally consider borrowing.  If nothing else, this visit has made me question aspects of our system I had considered to be gospel: viewed through the eyes of our visitors, I have had cause to question just about everything – why, after all, do we do it they way we do?

Erik Roskes is a forensic psychiatrist and currently the Director of Forensic Services at the Springfield Hospital Center in Maryland. The opinions expressed are those of the author only, and do not represent those of any of Dr. Roskes’ employers or consultees, including the Maryland Department of Health and Mental Hygiene. He can be found at http://mysite.verizon.net/eroskes/

Building a mental health system in Iraq

By Erik Roskes

As readers of this space are aware, I do not hold back on my critiques of our so-called “system” for dealing with offenders with mental illness.  Mental health staff in correctional settings, in particular, are always being asked – whether by state funders, or by contracted health care vendors, or simply because of their ever-growing caseloads – to do more with less.

But I am taking a hiatus from my soapbox to share a different view of some of the amazing things that are happening here in the US, looking through the lens of a country with services that were decimated by 30 years of dictatorial rule.

In September and October, under the auspices of SAMHSA (the Substance Abuse and Mental Health Administration, a division of the US Department of Health and Human Services), six teams from Iraq, each including psychiatrists, nurses, and social workers, will be visiting the US to engage with experts in the areas of substance abuse, trauma, women’s issues, child mental health, and forensic mental health.  I am privileged to be one of the organizers for the forensics team, who will spend four weeks engaging in a series of experiences within Maryland’s forensic services. They will be observing and interacting with specialized police interventions for people with mental illness, with mental health courts, with jails and prisons, and with forensic hospitals.  We anticipate a very active learning process – both for the Iraqi visitors and for their hosts here in the US.

We take so much for granted here.  We have an amazing participatory government, one in which too few of us take part.  Our Constitution is a living, growing document that still is meaningful and serviceable after 220 years.  We value rights more than perhaps any other nation in history.

Of course, there is much that is lacking here.  Our country and the various jurisdictions therein – my state of Maryland included – seem to be engaged in an orgy of incarceration.  Rather than treat, or rehabilitate – we punish.  Instead of working to make participating citizens, we throw away people even before their brains have finished maturing.

Other cultures do things differently.  Whereas we focus on liberty and autonomy, other countries focus on the value of the family as a unit.  I have learned that Iraq is one such culture.  Are we right?  Are they right?  What can we learn from one another, and from the way different cultures have chosen to do things?

Iraq has an estimated 100 psychiatrists for its estimated 31 million people – that is one psychiatrist per 100,000 people.  If 10% of people suffer with mental illness (a very conservative estimate given all of the trauma that Iraqis have experienced), then each Iraqi psychiatrist alone is responsible for the needs of 10,000 people.  Quite a caseload.  By contrast, there are about 38,000 members of the American Psychiatric Association – and perhaps two thirds of American psychiatrists – including many who work in correctional settings – are not members of this organization.  The US therefore has at least one psychiatrist per 8000 population, and possibly as many as one per 3000.  Things are even worse in terms of other mental health professionals: Saddam needed psychiatrists to medicate people, but he had little use for psychologists or social workers.

So, let’s all take a break from our critiques – they are valid, but they are built on a foundation that permits us to want things to be better, and a system that allows us to be change agents from within.  Things can always be better, but let’s not forget that for most of the world, they are a much, much worse.

In my next blog, I will tell you what we have shared with our Iraqi visitors, and what we have learned from them about doing more with less – a whole lot less.

Erik Roskes is a forensic psychiatrist and currently the Director of Forensic Services at the Springfield Hospital Center in Maryland. The opinions expressed are those of the author only, and do not represent those of any of Dr. Roskes’ employers or consultees, including the Maryland Department of Health and Mental Hygiene. He can be found athttp://mysite.verizon.net/eroskes/

'Dexter,' TV's Affable Serial Killer, Finds Fans In Criminology

Writing in Psychology Today, Bella DePaulo comments on the popularity--particularly among criminologists, apparently--of the Showtime TV network's "Dexter." Set in Miami, the 5-year-old show focuses on Dexter Morgan (played by Michael C. Hall), a police forensics expert who moonlights as a serial killer. The program won an Emmy Award this week for best directing in a drama series. DePaulo, a California psychology professor and writer, is editor of a new book,  "The Psychology of Dexter," that features analysis of the character by various experts in psychology, sociology and criminology.

DePaulo writes in the book, "While studying deception for decades, I thought I had come across just about every variation on the theme of living a lie. Then I met Dexter. Like everyone else who is living a lie, Dexter is hiding something almost every moment of his life. Unlike everyone else, though, Dexter is doing so with both hands tied behind his back. (Couldn't resist that analogy). As a psychopath (or a person with psychopathic tendencies), Dexter can't read people effortlessly. He doesn't have an intuitive sense of the right thing to do or to say. So he is always studying others for clues to how to seem, well, human. To me, this isn't just mindless entertainment; it is totally engaging - a tasty treat for the psychologically-minded."

Passing the Buck: How fragmented agencies keep the vulnerable stuck in the justice system

One of the more troubling issues I have encountered in my 15 years of the practice of psychiatry is the frequency with which agencies work to evade responsibility and accountability for the clients they are supposed to serve.  No agency is immune to this problem, but in my experience, one of the most egregious situations goes something like this:

Joe is a 33 year old man seen on the grounds of a local elementary school. He is not recognized by school staff, and the police are called.  Upon approach by police officers, he appears not to understand their direction to leave the grounds.

Instead, he approaches the playground area where the kindergarten class is currently playing.  The police officers take hold of his arms, at which point Joe begins screaming and fighting to extricate himself from their hold.  He is charged with trespassing on school grounds, resisting arrest, and two counts of assault on a law enforcement officer.

Upon entry into central booking, Joe does not answer any questions, instead sitting rocking on the bench.  Other arrestees tell detention staff “there’s somethin’ wrong with that dude – he’s crazy!”  Joe is referred for an urgent mental health assessment, where he stares over the evaluator’s head as if seeing someone behind the clinician.  He is placed in the mental health area of the booking center and a psychiatrist is called. The psychiatrist diagnoses Joe with schizophrenia and orders antipsychotic medication, which Joe refuses.  When taken for his bail review three days after his arrest, the court orders a competency assessment, and Joe is placed on the list for a forensic psychiatric evaluation.

When seen for the evaluation at the court clinic, Joe is still generally silent, but at times he echoes the last words of the questions posed to him.  He is found by the forensic evaluator to be incompetent to stand trial, and he is committed to the hospital for treatment and restoration to competency.  During his stay at the hospital, staff eventually are able to engage Joe sufficiently to track down Joe’s mother, who reports that “Joe was always a bit off. He was in special education classes at the school where he got arrested.”  When records from the school system are sought, the hospital staff are told “FERPA requires us to destroy special education records after 5 years.”

What is Joe’s real diagnosis?  It appears that instead of schizophrenia, Joe has a developmental disorder such as autism or a similar pervasive developmental disorder.  These types of disorders require very different treatment and rehabilitation approaches from the more familiar mental illnesses like schizophrenia or bipolar disorder.  Typically, mental illnesses respond to medications, while the developmental disorders require a more comprehensive behavioral approach.

More problematic is the system of care.  In many – perhaps most – states, one agency is responsible for the care of people with mental illness, and another is responsible for people with developmental disabilities such as autism or intellectual disabilities (formerly known as “mental retardation”).  Whereas people with mental illness can be hospitalized urgently if they meet civil commitment criteria (problem enough, as discussed in my June blog entry), those with developmental disabilities must prove that they are sufficiently impaired and that the impairment began in childhood before benefits are provided.  As the vignette illustrates, the childhood origin can be difficult to prove even when it is known where the individual attended school; it is often impossible to get even this information, if the person is unable to communicate or if he is from another country.  Thus, individuals who really require a behavioral approach to remedy or address their deficits end up in a psychiatric system that cannot say no, that is ill-equipped to manage them, and they are often inappropriately treated with medications that cannot be effective and that only lead to adverse effects over time.

I have consulted on cases and systems in many states, and I always hear the same thing: “How can we get these agencies to coordinate better?”

Erik Roskes is a forensic psychiatrist and currently the Director of Forensic Services at the Springfield Hospital Center in Maryland. The opinions expressed are those of the author only, and do not represent those of any of Dr. Roskes’ employers or consultees, including the Maryland Department of Health and Mental Hygiene. He can be found at http://mysite.verizon.net/eroskes/